The Canadian Cardiovascular Society Heart Failure Companion

Canadian Journal of Cardiology 32 (2016) 296e310
Special Article
The Canadian Cardiovascular Society Heart Failure
Companion: Bridging Guidelines to Your Practice
Jonathan G. Howlett, MD, FRCPC,a Michael Chan, MBBS, FRCPC, FACC,b
Justin A. Ezekowitz, MBBCh, MSc, FRCPC,c Karen Harkness, RN, PhD,d
George A. Heckman, MD, FRCPC,e Simon Kouz, MD, FRCPC,f
Marie-Helène Leblanc, MD, FRCPC,g Gordon W. Moe, MD, FRCPC,h
Eileen O’Meara, MD, FRCPC,i Howard Abrams, MD, FRCPC,j
Anique Ducharme, MD, FRCPC,i Adam Grzeslo, MD, CCFP,d
Peter G. Hamilton, MBBCh, FRCPC,c Sheri L. Koshman, PharmD, ACRP,c
Serge Lepage, MD, FRCPC,k Michael McDonald, MD, FRCPC,l
Robert McKelvie, MD, PhD, FRCPC,d Miroslaw Rajda, MD, FRCPC,m
Elizabeth Swiggum, MD, FRCPC,n Sean Virani, MD, FRCPC,o and
Shelley Zieroth, MD, FRCPC;p
for the Canadian Cardiovascular Society Heart Failure Guidelines Panels
a
University of Calgary and Libin Cardiovascular Institute, Calgary, Alberta, Canada; b Royal Alexandra Hospital, Edmonton, Alberta, Canada; c University of Alberta,
Edmonton, Alberta, Canada; d Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada; e University of Waterloo, Waterloo, Ontario, Canada;
f
Centre Hospitalier Re gional de Lanaudière and Universite Laval, Quebec, Quebec, Canada; g Institut Universitaire de Cardiologie et de Pneumologie de Que bec, Quebec,
Quebec, Canada; h St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada; i Institut de Cardiologie de Montre al, Montreal, Quebec, Canada; j University
of Toronto, Toronto, Ontario, Canada; k Centre Hospitalier Universitaire de Sherbrooke, Fleurimont, Quebec, Canada; l University Health Network, University of Toronto,
Toronto, Ontario, Canada; m QE II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada; n Royal Jubilee Hospital, Victoria, British Columbia,
Canada; o University of British Columbia, Vancouver, British Columbia, Canada; p St Boniface General Hospital, Winnipeg, Manitoba, Canada
ABSTRACT
RESUM
E
The Canadian Cardiovascular Society Heart Failure (HF) Guidelines
Program has generated annual HF updates, including formal recommendations and supporting Practical Tips since 2006. Many clinicians
indicate they routinely use the Canadian Cardiovascular Society HF
Guidelines in their daily practice. However, many questions surrounding the actual implementation of the Guidelines into their daily prac-
te
canadienne de
Le programme des lignes directrices de la Socie
ne
re
des
cardiologie en matière d’insuffisance cardiaque (IC) a ge
mises à jour annuelles sur l’IC, y compris des recommandations formelles et des conseils pratiques depuis 2006. De nombreux cliniciens
gulièrement les lignes directrices de la
indiquent qu’ils utilisent re
te
canadienne de cardiologie en matière d’IC dans leur pratique
Socie
The Canadian Cardiovascular Society (CCS) Heart Failure
(HF) Guidelines Program has generated annual HF updates,
including formal recommendations and supporting practical
tips for the past 9 years.1-9 Many clinicians indicate they
routinely use the CCS HF Guidelines in their daily practice
or as a reference for optimal care.10 Feedback from family
physicians, internists, cardiologists, nurses, pharmacists, and
others attending Guidelines Workshops held across Canada
have indicated that the Guidelines provide great value.11
They also indicated the need to address issues surrounding
Received for publication May 12, 2015. Accepted June 15, 2015.
E-mail: [email protected]
The disclosure information of the authors and reviewers is available from
the CCS on their guidelines library at www.ccs.ca.
Corresponding author: Dr Jonathan G. Howlett, Room C838, 1403-29th
St NW, Calgary, Alberta T2T 2X2, Canada. Tel.: þ1-403-944-3232;
fax: þ1-403-944-3262.
http://dx.doi.org/10.1016/j.cjca.2015.06.019
0828-282X/Ó 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
Howlett et al.
CCS Heart Failure Companion
297
tice remain. A consensus-based approach was used, including feedback from the Primary and Secondary HF Panels. This companion is
intended to answer several key questions brought forth by HF practitioners such as appropriate timelines for initial assessments and
subsequent reassessments of patients, the order in which medications
should be added, how newer medications should be included in
treatment algorithms, and when left ventricular function should be
reassessed. A new treatment algorithm for HF with reduced ejection
fraction is included. Several other practical issues are addressed such
as an approach to management of hyperkalemia/hypokalemia,
treatment of gout, when medications can be stopped, and whether a
target blood pressure or heart rate is suggested. Finally, elements and
teaching of self-care are described. This tool will hopefully function to
allow better integration of the HF Guidelines into clinical practice.
quotidienne. Cependant, de nombreuses questions entourant la mise
en œuvre effective de ces lignes directrices dans leur pratique quotie sur le consensus a e
te
utidienne demeurent. Une approche fonde
e, y compris les re
troactions des Panels d’IC primaire et secondaire.
lise
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pondre à plusieurs questions cle
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Ce vade-mecum est destine
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es par les praticiens spe
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lais
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valuations initiales des patients et les
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e
valuations subse
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dicaments
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dicaments devraient
doivent être ajoute
être inclus dans les algorithmes de traitement, et quand la fonction
value
e. Un nouvel algoventriculaire gauche doit de nouveau être e
jection re
duite est
rithme de traitement de l’IC avec une fraction d’e
es telles une
inclus. Plusieurs autres questions pratiques sont aborde
mie hypokalie
mie, le traitement de
approche de gestion de l’hyperkalie
dicaments peuvent être arrête
s, et si
la goutte, le moment où les me
rielle ou d’un rythme cardiaque est sugge
re
e.
une cible de pression arte
le
ments de l’autosoins sont de
crits.
Enfin, un enseignement et des e
gration des lignes diCet outil devrait permettre une meilleure inte
rectrices en matière d’IC dans la pratique clinique.
the implementation of the Guidelines into everyday practice.
Efforts are under way to implement Canadian benchmarking
of key performance indicators for HF care. Although there is
published information regarding hospital discharge medication use in patients admitted with HF, Canadian outpatient
data are limited to abstract publications from the Canadian
HF Network.12,13 These data show relatively modest use of
evidence-based therapies that increases in the HF clinic
setting. Because use of evidence-based therapies for HF is
closely related to best outcomes, the current Companion is
focused on providing a pathway to achieving optimal
treatment.
(2) How quickly and in what order should standard HF
therapy be titrated for most patients?
(3) When should I measure electrolytes, serum creatinine, and
blood urea nitrogen (BUN), and how should I manage
abnormal potassium or increasing creatinine levels?
(4) Should I treat my HF patients to a specific heart rate (HR)
or blood pressure (BP) and how often should I measure
left ventricular (LV) ejection fraction (EF)?
(5) Can I ever stop HF medications?
(6) When should I refer my patient to a heart surgeon?
(7) How should I manage gout in my patient?
(8) In what ways do I care differently for frail older patients
with HF?
(9) How do I teach self-care to my patients?
Who Is This Document Primarily Intended to
Reach? What Is the Format?
This document addresses the most commonly asked
practical questions that arise from those (in primary and
secondary care) who use these HF Guidelines and is written
with the main HF care provider in mind. Many of the suggestions and comments made in this article might also be of
interest to those who treat a large volume of HF patients or
who practice in a HF clinic setting. We have adopted a
question and answer approach to the structure of this document and have indicated where published evidence has
informed the responses. Otherwise, we have relied on procedures described in large randomized trials, or, where no
evidence exists, we have used expert consensus obtained by
polling all members of the primary and secondary HF panels
and have collated the responses (response rate 29 of 34 [85%])
to the questionnaire.14 We have also attempted to use
graphics, tables, and lists in a user-friendly manner that is
accessible via multiple formats so that the busy clinician might
conveniently use this tool.
In this report, we provide suggested answers to the
following questions:
(1) How soon should I see a newly referred HF patient; how
often should my HF patient be seen, and when can a
patient be discharged from a HF clinic?
How Soon Should I See a Newly Referred HF
Patient?
Table 1 shows situational wait time benchmarks for HF
referrals to a specialist.15 More than 86% of survey respondents agreed that routine referrals should be seen
within 4 weeks and 16% suggested this ideally be < 14
days.14
How Often Should My HF Patient Be Seen?
There are few published data regarding the optimal frequency of outpatient visits for patients with HF. Most
clinical trials that involved stable HF patients scheduled visits
every 3-4 months, with the assumption that primary and
specialist care was in place. Patients who are not stable or are
in the process of medical optimization should be seen more
frequently. Table 2 shows the time frames for which > 70%
of our respondents believe patients should be seen for HF
care (by whomever provides their HF care), based on their
risk.14 Patients often move from one risk group to another
after a sentinel event such as an emergency department visit
or hospitalization. A suggested pathway for initial and
ongoing assessments for patients with HF is shown in
Figure 1.
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Table 1. Situational wait time benchmarks for initial assessment of
patients with HF
Triage category/
access target
Clinical scenario
Emergent < 24
hours
Urgent < 2 weeks
Semiurgent < 4
weeks
Scheduled/routine
< 6 weeks
< 12 weeks
Acute severe myocarditis
Cardiogenic shock
Transplant and device evaluation of unstable
patients
New-onset acute pulmonary edema
HF in the setting of acute coronary syndrome
Progressive HF and/or decompensated HF
New diagnosis of HF, unstable, decompensated
New progression to NYHA IV, AHA/ACC
stage D
Postmyocardial infarction HF
Posthospitalization or ER visit for HF
HF with severe valvular heart disease
New diagnosis of HF, stable, compensated
HF with mild to moderate or NYHA II/III
symptoms
Worsening HF with therapy
Mild symptoms with valvular or renal disease or
hypotension
Chronic HF disease management, NYHA II
NYHA FC I symptoms, structural heart disease
without symptoms of HF (AHA/ACC stage B)
AHA/ACC, American Heart Association/American College of Cardiology;
HF, heart failure; NYHA, New York Heart Association; ER, emergency
room; FC, functional class.
Who Can I Discharge From My HF Clinic?
Panelists were split on this issue, with nearly 30% questioning whether those in the low-risk category required
ongoing follow-up in HF clinics.14 However, all agreed that
they should not be discharged without establishment of coordinated follow-up involving primary and specialist care.
Many of our panelists also believe that stable patients could be
followed in satellite clinics attended by a combination of
nurses and experienced internists or family doctors. All of our
respondents listed a minimum of at least 2 of the following
patient characteristics should be present to justify discharge
from a HF clinic:
Stable New York Heart Association (NYHA) I or II for
6-12 months.
Using optimal devices and pharmacological therapies.
Stable adherence to optimal HF therapy.
No hospitalizations for > 1 year.
LVEF > 35% (consistently shown if > 1 recent EF
measurement).
Reversible causes of HF controlled.
Follow-up by general practitioner interested in management of HF.
How Quickly and in What Order Should
Standard HF Therapy Be Titrated for Most
Patients?
Standard treatment of HF due to LV systolic dysfunction
(LVEF < 40%) now consists of triple therapy with an
angiotensin-converting enzyme inhibitor (ACEi) (or an
angiotensin receptor blocker [ARB] if ACEi not tolerated),
b-blockers and, mineralocorticoid receptor antagonists
(MRA).8 However, many practitioners prefer specific aids,
which might be used to help perform the mechanics of
titration. The CCS has developed online aids for the titration
of these medications that may be used by the individual
practitioner or as a supporting document for an approved local
protocol for physician extender/prescribers (such as nurse
practitioners or clinical assistants), in areas in which this
activity is allowed. These tools exist as a .pdf document,
PowerPoint slide set or iTunes appdwhich is available and
freely downloaded from the CCS HF Web site.16 In Figure 2,
Table 2. Recommended frequency of follow-up for patients with HF, by risk
Risk group
Low risk
Intermediate
High risk
Features defining risk of group
Suggested frequency of follow-up*
NYHA class I or II
No hospitalizations in past year
No recent changes in medications
Receiving optimal medical/device HF therapies
No clear features of high or low risk
NYHA IIIb or IV symptoms
Frequent symptomatic hypotension
More than 1 HF admission (or need for outpatient intravenous
therapy) in past year
Recent HF hospitalization especially in past month
Increasing creatinine level, especially GFR < 30 mL/min
Nonadherence to therapy for any reason
During titration of HF medications (ACEi/BB/ARB/MRA)
New-onset HF
Complication of HF therapy
Need to downtitrate or discontinue BB or ACEi/ARB
Concomitant and active illness (eg, high-grade angina, severe COPD,
frailty)
Frequent ICD firings (1 month)
At least yearly (90% suggested within 12 months, 50% within 6
months)
In certain cases might consider discharge of patient from clinic to
specialist office (in addition to primary care)
1-6 months
Minimum 1-2 visits per month
In some cases might be weekly assessments or even more
frequentdespecially if patient willing to undergo multiple visits to
potentially avoid a hospitalization
ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BB, b-blocker; COPD, chronic obstructive pulmonary disease; GFR,
glomerular filtration rate; HF, heart failure; ICD, implantable converter defibrillator; MRA, mineralocorticoid receptor antagonist; NYHA, New York Heart
Association.
* Many of these visits might be performed by telehealth or with allied health professionals supported in a multidisciplinary environment. The exact composition
will vary according to local resources, personnel, and practice standards.
Howlett et al.
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Figure 1. Recommended initial referral wait time and follow-up frequency. ACEi/ARB, angiotensin-converting enzyme inhibitor/angiotensin receptor
blocker; ACS, acute coronary syndrome; AHA/ACC, American Heart Association/American College of Cardiology; COPD, chronic obstructive pulmonary disease; D/C, hospital discharge; ER, Emergency Department; FC, functional class; HF, heart failure; hrs, hours; ICD, implantable cardioverter defibrillator; MI, myocardial infarction; NYHA, New York Heart Association.
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Figure 2. Therapeutic approach to patients with HF and reduced ejection fraction. ACE, angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; bpm, beats per minute; CRT, cardiac resynchronization therapy; HF, heart failure; ICD, implantable
cardioverter defibrillator; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; NYHA, New York Heart Association; SR,
sinus rhythm.
Howlett et al.
CCS Heart Failure Companion
we have modified the treatment algorithm for institution of
evidence-based therapies, including reassessments on treatment, for patients with HF due to LV systolic dysfunction. In
this algorithm, we have referenced therapies that are at present
under review by Health Canada and are expected to become
available in the near future.
b-Blocker and ACEi (or ARB) titrations should be
accomplished first (supported by > 80% of respondents),
although this does not have to occur in any specific order as
long as there is not undue delay in titration of the other.17,18
Typically, in patients with continuing HF symptoms, an
MRA is introduced when the ACEi titration is finished,
because both drugs can exert additive effects on serum potassium and creatinine. Consistent with the Guidelines, the
MRA should not be started or advanced in dosage if serum
potassium is > 5.0 or serum creatinine is > 220 mmol/L.8
The drugs used should be chosen from the CCS list of
medications that have evidence for reduction of HF symptoms, cardiovascular morbidity, and mortality.19 Titration
might take several weeks to months depending on disease
severity. Most of our panelists (55%) believe the entire triple
therapy titration to maximal tolerated or target doses should
be completed within 4 months, and 93% believe this should
be completed within 6 months. Titration of ACEi and
b-blocker only would be slightly less than this duration. All
respondents agreed that every titration would NOT necessarily require a face-to-face visit, unless there were clinical
concerns regarding the titration.
A Note on New Therapies
The astute reader will note 2 new medications in the
updated Figure 2. Ivabradine and LCZ696 have been noted in
previous HF Updates and are recommended for eligible patients. These medications should both be considered only
after standard triple therapy has been completed. The optimal
order of use for these medications is not known, however,
the careful clinician can consider the following issues:
(1) ivabradine is generally limited by HR, can be titrated over
2-4 weeks, and is generally well tolerated by those with
lower BP; and (2) LCZ696 is generally limited by
hypotensiondespecially those who are unable to tolerate
moderate or high doses of ACEi (or ARB)d and hyperkalemia. It is generally titrated over 6-12 weeks. At this time,
the order of titration will be individualized. These issues will
determine the order and rapidity of titration.
Helpful Links for the Practitioner
The CCS HF Medication Titration app (Med-HF) and
HF Guidelines app (iCCS) are available at: http://www.ccs.ca/
index.php/en/resources/mobile-apps.19 These apps contain a
detailed algorithm that can be used for all aspects of titration
of evidence-based medications for HF including ACEi, ARB,
MRA, and b-blockers. The iCCS Guidelines app can be used
for inquiry into any part of the Guidelines updates. In addition, an online tool, the HF Guidelines Compendium, can be
used to look up any subject related to HF, and the relevant
guidelines and/or practical tips will appear, irrespective of the
year published. As a result, the reader will always have access
to the most up-to-date recommendations with 1 easy query.
301
A link to the HF Pocket Document is available at: http://
www.ccs.ca/index.php/en/resources/pocket-guides.20 A link
to HF Educational Slide Decks is available at: http://www.ccs.
ca/index.php/en/resources/educational-slide-decks.21
When Should I Measure Electrolytes, Serum
Creatinine, and BUN?
In many HF clinics serum electrolytes, creatinine, and
BUN are routinely measured every 1-3 months in stable patients. Otherwise, our panelists suggest they also be measured
in the following settings:
For patients with advanced symptoms, measure with
each visit (or televisit).
Within 5-7 days of any intensification/addition of
diuretic therapy.
Within 7-10 days of and initiation or change in ACEi,
ARB, MRA, or nonsteroidal anti-inflammatory drug
(NSAID) therapy. This can be shortened to 3-5 days if
the earlier serum potassium is close to or > 5.0 mEq/L.
Within 1-2 days of sodium (calcium or sodium polystyrene) or calcium resonium usage or initiation/change
in potassium supplement therapy.
Early on during the course of any intercurrent illness
that might affect volume or renal status (eg, gastroenteritis, influenza, or after surgery).
Concomitant with any brain natriuretic peptide (BNP)
measurement because increasing creatinine might increase N-terminal (NT)-proBNP (but not BNP).
Remember that b-blockers (and certain newer medications such as neprilysin inhibitors) might increase BNP
levels.
How Should I Manage Hyper- or Hypokalemia in
My Patients?
Changes in diet, fluid balance, diuretic therapy, and drugs
that affect renal function (ACEi, ARB, MRA) might affect
serum potassium. For this reason, it is always important that
the patient understands to avoid or encourage potassium
intake in their diet, depending on their own potassium status.
Hyperkalemia and hypokalemia are both commonly seen
during the management of patients with HF. The former is
most commonly seen in patients who receive > 1 ACEi, ARB,
or MRA medication, or have diabetes or stage 3 chronic
kidney disease.22,23 Hypokalemia is most often seen with
combination or intravenous diuretic therapy, especially if a
thiazide, such as metolazone is used as part of the regimen.
Changes in these parameters are most common after drug
initialization and titration but > 20% of abnormalities might
occur many months after the introduction of a drug such as
MRA, necessitating the regular monitoring of serum
potassium.24
Although the text herein will provide general guidance as
to how HF experts in Canada manage serum potassium abnormalities, the Med-HF app (please see the section on
Helpful Links for the Practitioner) can also be used as a
specific guide.19 This app is also available as a PowerPoint
slide set or Adobe document.20,21
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Table 3. Suggested management approach for hyperkalemia, according to severity
Severity of
hyperkalemia*
Initial management
When to recheck electrolytes and
potassium
When to restart and/or retitrate RAAS
inhibitors
Usually not applicable
If RAAS agent has been stopped, restart
when serum potassium decreases to
within the patients usual level, or < 5.0
mmol/L, (whichever is higher) AND
Any concomitant condition contributing to recent changes is under control
When serum potassium decreases to
within the patients’ usual level, or < 5.0
mmol/L, (whichever is higher) AND
Any concomitant condition contributing to recent changes is under control
RAAS medications should usually be
reintroduced 1 at a time with intervening measurement of renal function
and electrolytes
When serum potassium decreases to
within the patients’ usual level, or < 5.0
mmol/L, (whichever is higher) AND
Any concomitant condition contributing to recent changes is under control
RAAS medications should usually be
reintroduced 1 at a time with intervening measurement of renal function
and electrolytes
Mild (serum Kþ 5.05.5 mmol/L)
Continue all RAAS unless new and
major increase in Kþ (if so, stop
most recently added RAAS agent)
Reinforce potassium restriction
Avoid other sources of Kþ
Ensure patient is not hypovolemic
Routine measurement unless Kþ has
been gradually increasing over time
If RAAS agent has been stopped,
recheck within 72 hours
Moderate (serum Kþ
5.6- 5.9)
Continue all RAAS at half previous
dose unless Kþ has been increasing
over time or major increase in Kþ (if
so, stop most recently added RAAS
agent)
Reinforce potassium restriction
Avoid other sources of Kþ
Ensure patient is not hypovolemic
Recheck Kþ and renal function within
72 hours
With repeated Kþ > 5.5, stop at least 1
RAAS agent and repeat measurement
within 72 hours
With a second Kþ > 5.5, consider calcium or sodium polystyrene 30 g
administration
Serious or severe
(serum Kþ > 5.9)
Contact patient to proceed to health
centre for clinical assessment and
12-lead electrocardiogram
Patient to undergo treatment according to local protocols for serious
hyperkalemia
Hold all RAAS agents until
reassessment
Within 4-24 hours, depending on local
acute hyperkalemia protocol (when
symptomatic or if there are electrocardiographic changes consistent with
hyperkalemia)
Again approximately 72 hours later
RAAS, renin-angiotensin-aldosterone system.
* The above actions are suggested based on the assumption that the potassium level is correctly measured. For instance, hemolysis of blood might occur, which
falsely increases the potassium level. In this instance, a repeat measure is necessary.
Hyperkalemia
The best treatment for hyperkalemia is prevention. In
general, patients who are given ACEi, ARB, or MRA should
be provided information on how to limit dietary potassium
intake and, if necessary, asked to stop drugs that affect potassium levels, such as NSAIDs, or especially potassium supplements (including salt replacement foods). In addition,
serum potassium levels might be falsely increased because of
hemolysis. Although many laboratories will not report serum
levels in a hemolyzed specimen, care should be taken to avoid
acting on such a level.
Drugs such as ACEi, ARB, or MRA should be used with
great care, or not at all in patients with glomerular filtration
rate < 30 mL/min because evidence for their benefit is lacking
in this situation.
Patients with serious hyperkalemia (> 6.0 mEq/L) should
be immediately contacted to determine their clinical status
and to proceed to the nearest health facility where indicated
management can be given (such as electrocardiographic
monitoring, intravenous insulin/glucose, salbutamol, and
calcium). Patients with serum potassium < 6.0 can usually be
managed in an ambulatory setting.
For clinicians who do not wish to use the Med-HF app,
Table 3 can serve as a general guide for treatment of hyperkalemia and is based on (but not identical to) algorithms used
in the Eplerenone in Mild Patients Hospitalization And
SurvIval Study in Heart Failure (EMPHASIS-HF) and Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) studies, in which different
ACEi, ARB, and MRA combinations were administered.25,26
In these studies, serious hyperkalemia (> 6.0 mEq/L) and
hypokalemia (< 3.0 mEq/L) occurred in < 5% of cases.26,27
This algorithm can apply to patients with HF (double or triple
therapy) and when spironolactone is used instead of
eplerenone.
Use of sodium or calcium polystyrene for treatment of
hyperkalemia is typically reserved for serious hyperkalemia
(> 6.0 mEq/L) or if conservative measures are not successful
for less severe hyperkalemia (> 5.5 mEq/L in consecutive
measurements). The need for repeated usage of this medication to reduce serum potassium typically should trigger a
reassessment of the medical regimen. Many clinicians use
polystyrene with a promotility agent, such as lactulose. This
might not be necessary for as needed use, but repeated use of
polystyrene agents might cause significant constipation.
Hypokalemia
Minimization of the use of intravenous loop diuretics and
loop and thiazide diuretic combination therapy will lessen
urinary potassium loss. Use of oral potassium supplements is
effective but associated with gastrointestinal upset. Divided
doses of slowly absorbed potassium, with titration according
to the response is suggested with an initial dose of 40-80 mEq
Kþ daily. One should consider chronic hypomagnesemia with
secondary urinary potassium wasting in patients receiving
chronic diuretics who present with refractory hypokalemia.
This might be remedied by administration of 250-500 mg
oral elemental magnesium per day.
Renal and electrolyte consequences of diuretic therapy
Increasing creatinine level is a common occurrence in the
HF syndrome, and hyponatremia is frequently seen in frail
Howlett et al.
CCS Heart Failure Companion
patients or those with advanced HF. The CCS published an
update in 2007,1 on which the Pocket Card, HF app and
Med-HF app19-21 are based. For full details we refer you to
these documents. However a few comments can be made
about the patient with increasing creatinine level (30% increase or > 26 mmol/L from baseline) or those with diuretic
resistance (waning of diuretic response over time, failure to
increase diuresis with increased diuretic dose, or urine volume
< 1500 mL) and hyponatremia (Na < 135 mEq/L).
Increasing creatinine level
(1) A common cause is hypovolemia. A volume assessment of
the patient is warranted and reduction/temporary cessation of diuretics.
(2) Avoid medication or substances that are known to affect
renal function such as NSAIDs.
(3) Proactively reduce use of diuretics during concomitant
episodes of dehydrating illnesses or periods of poor intake.
(4) Routine assessment of electrolytes and creatinine, especially in those who are receiving triple therapy and diuretics. Many clinics follow these tests every 1-3 months
although the optimal frequency is not known.
(5) Be extremely careful when using multiple diuretics,
because this will greatly increase the risk of hypotension
(rapid diuresis) and hyponatremia.
(6) Most clinicians will stop the MRA and reassess before
stopping the ACEi (or ARB).
(7) If these interventions fail, consultation with a nephrologist
might be needed.
(8) The more rapidly the creatinine changes, the more
frequent reassessment is required. Changes of > 20%30% in creatinine should be reassessed within 7 days.
Diuretic resistance and hyponatremia
(1) As noted on the Pocket Card, most clinicians will first
double the dose of loop diuretic. If there is a failure to lose
body weight within 48 hours, clinicians will change to
intravenous administration if feasible (same dose) or add a
thiazide diuretic. The third option is to use an intravenous
loop diuretic (either bolus or infusion) along with a
thiazide diuretic.
(2) It is critically important to avoid symptomatic hypotension in this instance.
(3) It is also important to supplement potassium and/or
chloride when they are deficient.
(4) Discontinue combination diuretic therapy as early as
possible.
(5) Use of acetazolamide for management of metabolic alkalosis
might be helpful if diuretics cannot be reduced, and tolvaptan
is highly effective when serum sodium is < 130 mEq/L.
(6) Patience is important, a less aggressive goal of 0.5 kg per
day of body weight reduction (or less in some cases) will
allow for less diuretic-induced renal and/or electrolyte
imbalance.
(7) It is important to ensure the patient is adherent to an
acceptable fluid restrictiondthis is usually < 2000 mL
per 24 hours. Recently, more aggressive fluid restrictions
of 1000-1500 mL have come under question but might
rarely be needed temporarily.
303
(8) It is also critically important to ensure that optimal
treatments of the HF syndrome (vasodilator, treatment of
hypoxia, tachycardia, etc) are enforced.
Should I Treat My HF Patients to a Specific HR
or BP?
Current HF Guidelines are based on the concept that we
use targets to identify when to initiate therapy. When an
evidence-based therapy is initiated, it is titrated until the target
dose is reached or intolerance occurs. However, a few comments can be made.
Blood pressure
Avoidance and treatment of systemic hypertension has long
been a critical aspect of HF treatment and prevention.
Available evidence indicates that patients with lower resting
BP,28 or who experience episodes of symptomatic hypotension also suffer greater morbidity and mortality compared
with those with normal BP.29,30 This is also true during acute
HF.31 In contrast, evidence-based therapies for HF with
LVEF < 40% have been shown to confer at least as good a
benefit irrespective of the starting BP, provided the medication is tolerated.32 Indeed, many patients with low BP might
do very well with evidence-based therapies.
Apart from control of systemic hypertension, no BP
must be targeted as long as the patient is not symptomatic because of low perfusion.
There is no consensus on which BP is optimal, although
some HF clinicians will empirically try to keep systolic
BP < 110-120 mm Hg for patients with very low
LVEF. The rationale is to reduce cardiac afterload,
despite a lack of outcome evidence.
There is observational evidence that symptomatic hypotension should be avoided during acute HF.
Hypotension can complicate titration of evidence-based
therapies such as ACEi, ARBs, or b-blockers. These
simple strategies can be used to greatly reduce the likelihood of this problem:
(1) Staggering of any vasoactive medication such that no
2 such drugs are given within 2 hours of each other.
(2) Splitting medications into smaller, more frequent
dosages might be helpful.
(3) Many clinicians prescribe b-blockers to be taken
with meals to slow down absorption.
(4) Reduce or discontinue other medications (if
possible) that lower BP but do not alter prognosis,
such as calcium or a-blockers.
(5) Titrate vasoactive medications more slowly and
avoid titration when there is hypovolemia present.
Heart rate
Resting HR is directly related to mortality in patients with
HF.33,34 Decrease of an initially increased HR is associated
with improved mortality, which is in turn associated with the
degree of lowering of the HR.33 In the past, resting HR was
used only to identify whether approved b-blockers could be
administered or titrated upward to the target dose.8 Most
clinicians would accept a resting HR of 50-60 beats per
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Volume 32 2016
Table 4. Suggested timing for measurement of LVEF, according to clinical scenario
Clinical scenario
Timing of measurement
Modality of measurement
Comments
New-onset HF
Immediately or within 2 weeks
for baseline assessment
ECHO (preferred when available); or
MUGA or CMRI
Following titration of triple
therapy for HFrEF, or
consideration of ICD/CRT
implantation
Stable HF
3 Months after completion of
titration
ECHO or MUGA or CMRI
(preferably the same modality and
laboratory test as initial test)
70% request ECHO and 30% MUGA; report
should include numeric EF or small range of
EF and diastolic function evaluation
LVEF after medical therapy might increase,
obviating device therapy
Approximately every 2-3 years,
especially if EF is > 40%
ECHO or MUGA or CMRI
Within 30 days, during
hospitalization if possible
Not necessary when repeated
admissions occur without
need to identify a cause
ECHO or MUGA or CMRI, cardiac
catheterization in context of ACS
After significant clinical event
(ie, after some HF
hospitalizations)
Rationale is to identify improving (better
prognosis) or worsening ventricular function
(worse prognosis, need for additional
therapy such as ICD/CRT)
Frequently helpful information such as EF,
degree of valvular dysfunction, and RVSP
ACS, acute coronary syndrome; CMRI, cardiac magnetic resonance imaging; CRT, cardiac resynchronization therapy; ECHO, echocardiogram; EF, ejection
fraction; HF, heart failure; HFrEF, HF with reduced EF; ICD, implantable cardioverter defibrillator; LVEF, left ventricular EF; MUGA, radionuclide angiography;
RVSP, right ventricular systolic pressure.
minute (bpm) or as low as tolerated (usually not < 50 bpm).
Increased HR (> 70-75 bpm) after b-blocker titration can
identify patients with LVEF < 35% who might benefit from
the Ikf or ‘funny’ channel blocker ivabradine (soon available in
Canada), which directly decreases HR in patients in sinus
rhythm. However, even in this setting, the intent is to titrate
the medication to the target of 7.5 mg twice daily as long as
the medication is tolerated, not to a specific HR. For patients
with atrial fibrillation, the evidence linking resting HR and
outcomes is poor.
HR is used to determine eligibility for b-blocker initiation and titration; the medication should be titrated to
target dose if tolerated. This is also true for other HRlowering drugs.
In the case of atrial fibrillation, b-blockers are
preferred. There is no specific target associated with
optimal outcome although many suggest a rate < 80100 bpm.
I Know I Should Get a Baseline Measure of
LVEF, but Should I Measure It Again? If So,
When Should It Be Measured?
It has been shown that LVEF might change substantially
over time.35,36 Indeed, approximately 25% of patients with
initial LVEF < 40% (HF with reduced LVEF) might gain an
increase to > 40%. These patients have an excellent prognosis. Conversely, 25% of patients with initial LVEF > 40%
(HF with preserved EF [HFpEF]) might experience a decrease
in LVEF < 40%.36,37 Finally, in patients with initially low
LVEF, it is necessary to document the response of EF to triple
therapy to assess eligibility for implantable cardioverter defibrillator and/or cardiac resynchronization therapy. One
schedule for measurement of LVEF is shown in Table 4.
What About Measurement of BNP or
NT-proBNP?
Natriuretic peptides (NPs) are increasingly a part of the
management of HF. In 2015, the CCS recommended the use
of NPs in several clinical scenarios.9 It is important to
recognize that access to NP is variable across Canada, and so
use will vary from region to region and according to indication. The following clinical scenarios for which BNP will
commonly be measured are noted in the following list of
scenarios. Scenarios 1-3 are more strongly advocated in the
Guidelines.
(1) All patients on assessment in the emergency department
with suspected but not proven HF.
(2) At end of titration of triple therapy for those with LVEF
< 40%. In this situation, increased NP level might lead to
a change in ACEi (or ARB) therapy to LCZ696.
(3) In patients with stable HFpEF in whom an increased NP
level will lead to additional use of an MRA.
(4) In patients who are at risk of HF in whom elevated NP
level will lead to closer follow-up.
(5) Before hospital discharge (when admitted for HF) in situations in which an increased level will change the followup plan, such as admission to a HF clinic.
(6) In patients followed by HF clinics who wish to use NPs to
guide therapy.
Can HF Medications Ever Be Stopped? If So,
Then When?
Guideline-directed medical therapy (GDMT) for patients
with HF and reduced EF (< 40%) has dramatically changed
the long-term natural history of the disease.8 These drugs
include ACEi inhibitors, ARB, MRA, and b-blockers. In an
African American subset of moderately severe HF patients, the
combination of nitrates and/or hydralazine is also diseasemodifying. In contrast to these drugs, several other agents
such as loop diuretics, thiazide diuretics, nitrates (alone),
digoxin, and other drugs have not changed the long-term
natural history of HF and can be stopped in the absence of
symptoms and/or congestion.
Indeed, > 90% of our panel agreed that ACEi/ARB, bblockers, and MRA agents, once indicated, should be given
indefinitely.
Howlett et al.
CCS Heart Failure Companion
305
However, 4 important points must be raised. First, many
patients were excluded from clinical trials that involved
GDMT including those with clearly reversible causes or specific forms of HF, many of which are outlined in Table 5.38
Second, withdrawal of chronic ACEi/b-blocker therapy for
patients with dilated cardiomyopathy (ischemic or nonischemic) whose LVEF improved with triple therapy will
result in a 60%-80% likelihood of recurrence of low LVEF,
usually with symptoms.39 As such, withdrawal of these
medications should only be considered after consultation with
a physician experienced and competent in the treatment of
HF. Finally, reassessment of LVEF should occur within 3-6
months after withdrawal of GDMT and periodically thereafter, with any reduction of LVEF prompting reconsideration
of the plan.
Our committee agreed that in a few specific situations,
listed below, HF medications might be withdrawn if certain
circumstances are present as listed in Table 5.
What About HFpEF?
Unfortunately, we still do not have proof that any specific
medication will prolong life in patients with HFpEF.9 However, evidence is increasing that we can reduce symptoms and
improve quality of life in this condition, and recent studies
suggest that MRA might be useful in those with increased NP
level.9 As mentioned in previous updates, our suggestions for
treating HFpEF remain:
(1) The same recommendations for initial referral, repeat
assessment, and measurement of LVEF and NP are
identical irrespective of the type of HF.
(2) Use of b-blockers for concomitant conditions, such as
previous myocardial infarction or angina.
(3) Use of ACEi or ARB in most patients.
(4) Use of MRA for patients who have had an increased NP
level.
(5) Correction of any condition, such as systemic hypertension, valvular heart disease, cardiac ischemia, or tachycardia and/or atrial fibrillation that might have aggravated
or precipitated HF.
(6) Treatment of concomitant comorbid conditions.
(7) Use of minimal doses of diuretics necessary to maintain
euvolemia.
(8) Access to HF clinics, cardiac rehabilitation, and self-care
management as per any other patient with HF.
How Should I Manage an Acute Episode of
Gout?
Gout is a common complication of loop diuretic therapy,
and frequently occurs during HF decompensation. NSAID
agents should be avoided as shown in Table 6.
Is My Patient a Candidate for Heart Surgery?
Surgical coronary revascularization, mitral (or even
tricuspid) valve repair, and (in carefully selected cases) LV
aneurysm resection might have a profound effect on mortality,
symptoms, and subsequent hospitalization.4,44,45 As such,
patients with HF should always be assessed for conditions
amenable to surgical therapy. This action is typically performed on initial diagnosis of HF, but should always be a
consideration after any major change in the clinical HF syndrome (especially if there is a heart murmur, symptoms of
potential cardiac ischemia, or a significant change in assessment on echocardiography).
In general, most patients with HF will present without
evidence of obvious cardiac ischemia or primary valvular
pathology. In this setting, optimal medical care is instituted
with a reassessment of LVEF, and surgical considerations are
undertaken, if appropriate. In the minority of HF patients
who present with ischemic cardiomyopathy or other structural cardiac abnormality, this surgical assessment will occur
much earlier and before LV reassessment. Because advances
in surgical therapy for HF continue to occur, surgical candidacy should be assessed (or reassessed!) at a high-volume
surgical centre that provides advanced surgical therapies
such as mechanical circulatory support and heart
transplantation.
Table 5. Potential scenarios in which evidence-based medical therapy for heart failure might be withdrawn
Clinical presentation
Tachycardia-related CM
Alcoholic CM
Chemotherapy-related CM
Peripartum CM
Valve replacement surgery
Conditions to justify withdrawal of
GDMT after 6-12 months of therapy
Normal EF (> 50%)
NYHA FC I
Underlying tachycardia controlled
Normal EF
NYHA FC I
Abstinence ETOH
Normal EF
NYHA FC I
No further drug exposure
Normal EF
NYHA FC I
Normalization of EF
NYHA FC I
Normally functioning valve
Comments
Usually due to atrial fibrillation/flutter with increased HR, might rarely occur because
of PVCs. Might need BB for rate control
Nutritional deficiency might coexist and require therapy
Might need control of obesity and obstructive sleep apnea
Certain types of chemotherapy (trastuzamabdhigh rate of LVEF improvement when
it is stopped) are more likely to reverse than others (anthracyclines for which therapy
should be continued)
Long-term surveillance strongly recommended
Repeat pregnancy might be possible for some.40-42 Consultation at high-risk maternal
centre should be undertaken
Less consensus on regurgitant lesions with ongoing dilation of LV
BB, b-blocker; CM, cardiomyopathy; EF, ejection fraction; ETOH, ethanol; FC, functional class; GDMT, guideline-directed medical therapy; HR, heart rate;
LV, left ventricle; LVEF, left ventricular EF; NYHA, New York Heart Association; PVC, premature ventricular contraction.
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Volume 32 2016
Table 6. Potential approaches to treatment of acute gout in patients with HF
Type of therapy
Acute gouty attack
Oral colchicine
Oral prednisone
Type of gout
Any type
Polyarticular gout, or inability to
treat with colchicine
IA steroid injection
Monoarticular gout. Not suitable
for polyarticular gout
Chronic prevention of gouty attacks
Colchicine
Can reduce attack frequency
Allopurinol
Febuxostat
Probenecid
First-line agent for reduction of
uric acid
Second- or third-line agent
Dosage and duration of therapy
Dosage adjustment
1.0-1.2 mg then 0.5-0.6 mg every 2 hours
until pain relief with maximum of 3 mg
per 24-hour period.
May be used to abort gouty attack if used
early enough
Prednisone, 0.5 mg/kg daily with rapid
taper over 7-14 days
Not recommended for GFR < 15 mL/min
High rate of diarrhea with aggressive
dosing. Many will use only a single dose
of 0.6 mg after first dose
IA triamcinolone 20 mg once
IA cortisone 100 mg once
0.6 mg daily or twice per day in function of
GFR
300 mg daily orally
40-80 mg daily orally
250 orally twice per day to maximum 1000
mg twice per day
No adjustment needed
Can be given intravenously or orally and
might not worsen acute HF43
None required
Not recommended for GFR < 15 mL/min
Dose reduction for renal disease.
200 mg daily for GFR < 30 mL/min
100 mg daily for GFR < 20 mL/min
50 mg daily or 3 times weekly if ESRD
Reduce for GFR < 30 mL/min
Multiple drug interactions
Avoid if GFR < 30 mL/min
ESRD, end-stage renal disease; GFR, glomerular filtration rate; HF, heart failure; IA, intra-articular.
In What Ways Do I Care Differently for Frail
Older Patients With HF?
Although the CCS HF Guidelines endorse that most of the
recommendations for management of HF also apply to
seniors, their successful implementation requires careful
consideration of concurrent geriatric syndromes as stated in
the 2006 HF update.2 Frailty is commonly understood as a
state of increased vulnerability that generally occurs among
older persons, and arises from the presence of multiple deficits
across multiple systems.46
Key points47
The diagnosis of HF in older patients is complicated by
nonspecific symptoms of shortness of breath, fatigue,
fall, loss of autonomy, cognitive impairment, and incontinence, and overlaps with other common comorbidities. Clinicians should have a high index of suspicion
for HF in this population.
NPs are particularly useful for diagnosis of HF in older
patients because of the increased difficulty of diagnosis.
Most recommended HF therapies are effective in older
patients and can be consistent with their goals of care,
including alleviation of HF symptoms.
Successful management of HF in older patients is most
feasible in a chronic disease management setting.
Clinicians should have early and frank discussion with
patients and their families about the end-of-life preferences, and provide palliative care in appropriate patients.
I am concerned that increasing the doses of indicated HF
medications in older HF patients would lead to falls
The CCS recommends GDMT at target doses as tolerated
in all patients irrespective of age. However, symptomatic
cerebral hypoperfusion resulting from excessive doses of
medications is an important mechanism of falls in older
persons. This is often exacerbated by volume depletion,
because of diuresis and is compounded by their reduced
thirst and renal salt retention. HF measurement of orthostatic vital signs, including immediately after standing, is an
essential manoeuvre in assessment of volume status in an
older person.
Splitting daily doses of medications might help avoid the
peak effect of a larger dose.
Avoidance of hypovolemia with less aggressive diuresis
or through permissive reduction of diuretic or ACEi
during titration of b-blockers might reduce the risk of
hypotension.
Routine surveillance of electrolytes and renal function is
essential.
Persistent peripheral edema might be due to venous
insufficiency or calcium-channel blockers and might
persist despite adequate diuresis.
How Can Complaints of Urinary Frequency and
Incontinence Be Addressed in Older HF
Patients?
Urinary frequency, nocturia, and incontinence are common among older persons and are often attributed to the use
of diuretics. This might affect patient adherence. However,
urinary frequency or nocturia might occur because of
increased intravascular volume from suboptimal HF control,
nocturnal mobilization of peripheral edema in the recumbent
position, and sleep apnea.47
A focused clinical history will help identify potential HFrelated precipitants of urinary complaints:
Ask about urinary symptoms, especially frequency and
incontinencedpatients might not volunteer this
information.
Assess volume status to identify volume overload.
If incontinence is linked to an ACEi cough, consider
changing to an ARB.
Howlett et al.
CCS Heart Failure Companion
307
Table 7. The 3 elements of HF self-care58
Self-care terms
Maintenance
Monitoring
Management
Self-care activities
Behaviours to reduce risk factors, improve health, and
adhere to recommendations (eg, follow dietary
restrictions, take medications as prescribed, exercise
regularly)
Routine daily monitoring/vigilance to HF symptoms (eg,
daily weights, checking for edema) and recognize a
change when it occurs
Evaluate a change in symptoms and determine what action
is needed (eg, do nothing, call a health care provider).
Evaluate the effectiveness of the action
HF, heart failure.
A high index of suspicion for presence of sleep apnea in
elderly HF patients is warranted.
The management of persistent peripheral edema in the
setting of optimal intravascular volume includes:
Discontinuation of offending medications such as
calcium-channel blockers.
Elevate the head of the bed and/or use compression
stockings.
Administering diuretics after the midday meal, leaving
the patient relatively more volume-depleted at bedtime.
Patients might prefer to either avoid or to self-administer
diuretics after a long excursion, rather than before. By
allowing them to do this, adherence might increase.
Persistent urinary complaints should trigger referral to a
clinician specialized in incontinence management.
Why Are My Older HF Patients Continuously
Readmitted Despite My Best Efforts?
Elderly patients with HF are more likely to suffer additional comorbid conditions in addition to HF.48,49 Repeat
hospitalization, approximately 50% of which is because of
noncardiac causes, is thus more likely to occur in this group of
patients.48,50 In addition to a properly executed hospital
discharge, extra care should be taken to identify potential
causes of readmission, which if found, can be addressed
directly or with prompt specialist referral47,51:
Screening for cognitive impairment (such as with the
Montreal Cognitive Assessment; minor training might
be required).52,53
Screening for major depression, using well-known
screening tools.54-56
Screening for frailty, such as with the Canadian Study
on Health and Aging Frailty Scale or 5-second walk
distance at discharge.46
Poor nutrition and/or poor adherence to medical devices.
Management of complex HF patients should occur in
multidisciplinary disease management clinics, with close
involvement of the primary care clinician.47
Other referrals to consider include:
Pharmacy services;
Home care services;
Community support services (eg, Meals on Wheels,
Alzheimer’s Society);
Specialized Geriatric Services.
How Do I Teach Self-Care to My Patients?
Self-care in HF is often described in the context of behaviours necessary to maintain or promote health and lifestyle
changes and manage the symptoms and effects of living with
HF.57,58 The basic elements of self-care are shown in Table 7.
Topics relevant to self-care in HF are well documented.58,59 Although patient education is necessary, simply
providing patients with the standardized information is
insufficient for optimization of self-care.60,61 The key points
for optimization of self-care in patients with HF are listed in
Table 8.
Table 8. Tips for optimizing self-care in patients with HF58-66
Factors that affect self-care
Confidence
Cognitive status
Emotional status
Relationship with HCP
Learning environment
Teaching approach
Personalization of self-care
symptom monitoring and
management
Family and caregivers
Social support
Tips
Self-care confidence is a modifier and mediator of success. Strategies to improve patient self-care confidence include:
counselling to recognize benefits and help overcome barriers of self-care, reinforcing positive behaviours, setting mutual and
realistic goals, and celebrating successes
Consider screening (eg, MOCA) for cognitive impairment and literacy level in patients with ongoing challenges with engaging
in self-care
Consider screening for depression/anxiety in patients with ongoing challenges with engaging in self-care
Relationships require trust, and need to be collaborative, reciprocal, and respectful. HCPs need to view patient as a partner and
adopt a collaborative approach
Patients need a safe environment (eg, not punitive) to explore real or potential situations in which self-care is difficult. Creative
problem-solving, cognitive-behavioural strategies, and mutual goal-setting are necessary
Self-care is a skill and requires practice and learning over time. Information on ‘how’ to apply self-care information into daily
lives is necessary. Help patients work through their experience and strategies for self-care as opposed to reiterating self-care
tasks and recommendations. Teach-back technique has been shown to be effective
HCPs can be ‘detectives’ and help patients decipher their unique and early symptoms of HF exacerbation from other
symptoms that they might have attributed to HF.
HCPs can help patients identify individual patterns of symptoms of deterioration and help construct decision aides to help
them navigate key stages in the decision-making process around self-care
Caregivers often provide a substantial amount of support for patient self-care activities and need to be seen as partners in the
overall care plan. Their contribution to self-care cannot be underestimated
Social support can be in the form of emotional, instrumental, informational, or appraisal. Assess for the need to enlist
additional formal resources to support necessary self-care activities and behaviours for people with inadequate social support
systems
HCP, health care provider; HF, heart failure; MOCA, Montreal Cognitive Assessment.
308
Conclusions
Guidelines form the basis for the provision of high-quality
care for patients with HF, and underpin the development of
best practices and the assessment of quality of care. The CCS
has published comprehensive HF Guidelines and annual updates for the past 10 years. This Guidelines Companion has
been developed in response to key practical questions that are
unlikely to be answered by randomized controlled clinical
trials. For the first time, we articulate answers to how soon and
how often patients with HF should be seen, when they should
be reassessed, how new therapies should be incorporated into
treatment algorithms, and many other important questions. It
is our hope that the HF clinician can use this tool to better
integrate HF Guidelines into their busy practices.
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